Healthcare Provider Details

I. General information

NPI: 1164547972
Provider Name (Legal Business Name): LYDIA CRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15248 11TH ST
VICTORVILLE CA
92395-3704
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 760-245-8691
  • Fax: 761-843-6050
Mailing address:
  • Phone: 818-845-6206
  • Fax: 626-396-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA26050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: